Nevada Administrative Code
Chapter 616C - Industrial Insurance: Benefits for Injury or Death
DETERMINATION AND PAYMENT OF BENEFITS
Claims for Compensation
Section 616C.097 - Statement on written notice of determination regarding disagreement with determination

1. Any written notice of a determination by an organization for managed care that relates to accident benefits must include at the bottom of the notice a statement in substantially the following form:

If you disagree with the above determination, sign, date, and briefly explain on the bottom of this notice the reason for your appeal and return this notice to the organization for managed care at the address indicated within 14 days after the date on which this notice was mailed by the organization for managed care.

2. Any written notice of a determination by an insurer or third-party administrator that relates to benefits, other than accident benefits, must include at the bottom of the notice a statement in substantially the following form:

If you disagree with the above determination, sign, date, and briefly explain on the bottom of this notice the reason for your appeal and return it to the Hearing Officer at the Department of Administration within 70 days after the date on which the notice was mailed by the insurer or third-party administrator.